How would I go about getting my insurance to pay for a breast reduction? I have been suffering with very large breasts for years, and this is creating more and more difficulties for me.

Tina

Insurance contracts contain specific provisions for what is covered and what is not. Comprehensive major medical plans often include medical and surgical benefits for medically necessary treatments and procedures. Most plans exclude elective procedures, and services like plastic surgery typically fall into this category.

The application of medical necessity, however, can bring plastic surgery into the realm of covered services. Breast cancer patients are often covered for reconstruction of the affected breast. A child born with a cleft lip is often covered for the surgery necessary to correct it. An accident victim may require reconstructive surgery on the face. In other words, plastic or reconstructive surgery is not always elective.

You need to find out how your insurance company handles questions of medical necessity. If you have an individual (non-group) plan, read your policy. If you have a question, call your insurance company and ask to talk to someone in the claims department or insurance benefits area. Ask them how the company treats matters of medical necessity not specifically explained in the policy. You may find out that the company will respect the opinion of a physician as to what constitutes a medical necessity. The insurance carrier may also ask a second physician to review the opinion of your doctor.

If you have group coverage, you will want answers to the same question. You can start by going to your company's benefit manager. That person may refer you to someone at the insurance company. If you are covered by an HMO, you may want to call customer service, or start with your primary care physician.

The central question here is whether the breast reduction is a medically necessary procedure. Knowing how your insurance carrier treats such matters is important for the next step, which is to talk with your physician. Your doctor will certainly know what kind of health problems you have now or risk having in the future. Ask your doctor for information on all the options, and determine whether the doctor believes that breast reduction is medically necessary. If so, you and your doctor can talk to the insurance company to find out whether it will be covered by the plan. You may have to get a second opinion.

If you are suffering from pain or other problems resulting from large breasts, chances are that the insurance plan will want to help you. By covering breast reduction, you might avoid other, more costly health problems in the future. Work with your insurance company and your doctor toward a solution.